Basic Information
| Provider Information | |||||||||
| NPI: | 1023334141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SALIDA HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HRRMC ED PHYSICIANS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 429 | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812010429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302200 | ||||||||
| FaxNumber: | 7195302230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 RUSH DR | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812019627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302200 | ||||||||
| FaxNumber: | 7195302230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2010 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FAGERBERG | ||||||||
| AuthorizedOfficialFirstName: | LESLEY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7195302213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SALIDA HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 010628 | CO | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 004020392 | 05 | CO | MEDICAID |